The inspection took place on 4 October 2017 and was unannounced. At the last inspection on the 7 September 2016, the service was rated as requires improvement in every key line of enquiry we inspect against and had three breaches: Regulation 9. Person centred care. Regulation 18. Staffing and Regulation 17. Good governance. At the last inspection, there was a manager newly in post who has since been registered with the Care Quality Commission. At our most recent inspection, we identified improvements in all areas although there were still some concern about staffing levels and whether there was sufficient skill mix on shift. Staff recruitment remained a difficult area for this service and for the care sector in general.
The service is for older people who require residential care, some of whom may be living with dementia. The home could accommodate up to 74 people in single, en-suite rooms. Accommodation was over two floors with the dementia unit on the ground floor. On the day of our inspection there were 70 people using the service.
There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We found the home had improved and had worked hard to meet its own action plans. The home was well led and the staff we spoke with were very professional, knowledgeable and provided care centred around the needs of each individual. At the last inspection, we reported on a breach of regulation in regards to staffing levels. At this inspection there were enough staff to provide care people needed in a safe way. However, we saw there were difficulties around the recruitment and retention of staff and agency staff were being regularly used. Ensuring there were staff with sufficient skills and experience was also a challenge for the service given a recent vacancy of unit leader and only a small number of senior staff who could lead and direct the shift.
Staff spoken with were familiar with safeguarding protocols and how to protect people as far as reasonably possible from abuse. The home was proactive in reporting any concerns of alleged or actual abuse. They told us they reported anything of concern and brought it to the attention of the local authority. They worked with other agencies to try to support people with their anxieties and distressed behaviours. We received feedback about this and were told that a consistent approach was not always used and the guidance in people’s care plans not always sufficiently detailed to support staff to work in a consistent way. We observed staff and found their approaches consistent and calm in the way they approached people.
Medicines were well managed and people received them as intended. We identified an issue with recording but were given immediate assurances that this would be addressed.
Risks to people’s safety were managed well and there were enough staff to deliver care as needed. There was sufficient management oversight of risk. This helped ensure people received safe care and treatment.
Robust staff recruitment processes were in place and helped recruit staff with the right attitude and skills for the job
Staff were supported through induction, training and ongoing support to help develop their confidence and competencies. A lot of staff had transferable skills and qualifications from their country of origin. For staff new to care, a nationally recognised induction, the care certificate, was used by way of introduction and covered all the key skills and competencies.
People were supported according to their preferences but engagement with people, their relatives and staff in the planning of care needed further consideration. Staff acted lawfully in terms of supporting people who lacked capacity to make informed decisions for themselves. Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process.
Staff had sufficient understanding of legislation underpinning human rights, equality and diversity and mental capacity. They demonstrated this through their approach to person centred care.
People were supported to stay healthy and to receive health care as and when required. Staff had an understanding of long-term conditions people had and monitored these so they could identify any changes, which might require medical intervention.
People were supported to eat and drink enough for their needs and there was monitoring of people’s weights, which provided information staff could act upon if unintentional weight loss was identified. There were good systems in place but the occasional gap in audits and records could potentially mean that actions taken to support a person would not be timely.
People received care based around their needs and wishes and this was documented. Some restrictions were observed due to available staffing, for instance planned activities were not yet available seven days a week and some people were requesting to go outside and were reliant on staff to facilitate this. We did not observe staff offering to do this. There was no transportation at the service to enable trips to take place. We noted good engagement with relatives but less so with the local community which would enhance people’s experiences and help them live well. The activities we saw taking place were good, and increased people’s well- being.
Staff were observed enhancing people’s health and well- being. They were polite, considerate and knew people well. There was a lovely atmosphere throughout the home with staff supporting each other and providing unhurried, timely care. Care was provided on an individual basis but people had limited opportunities to feedback their experiences. Surveys were used for feedback and issued every six months. Regular relative meetings also took place and some people had good input from other health care professionals. People were involved in their plan of care where they were able. However there were no resident meetings and it was not clear how some people would articulate any concerns or improvements they may wish to see.
The environment had been created to provide stimulation for people living there. The layout helped people walk with purpose without restrictions. There were areas of interest and lots of tactile objects and things to stimulate people visually. The environment was clean and personalised for each individual. People on the ground floor had access to the gardens and people upstairs could access the garden with support.
There was a robust complaints procedure and other means for people to feedback including regular audits of the service. The director was at the home during our inspection and visited each week and informally audited the service although the outcome of their visit was not always recorded so we could not see what actions had been identified. All the staff knew the director and said they were friendly and approachable.
The home was well-led with most staff expressing confidence with the manager and reporting positively on the changes they had seen. The biggest threat to the service was recruitment and retention of staff especially given the high level of need and supervision required by some people using the service.
There were systems in place to try and continuously improve the service and ensure people’s needs were met. We found systems robust but did find gaps in the frequency of audits and found not all records as robust as we would expect. However, we did not see any evidence that this had reduced the quality of service.
The home was well supported by health care professionals and relatives of people using the service. The manager also attended a number of forums and had contact with other home managers in the county. This helped them keep up to date with best practice and share ideas in a mutually supportive setting